RD181 - Development of a Nursing Facility Quality Improvement Program Using Civil Money Penalty Funds


Executive Summary:
Chapter 474 of the Virginia Acts of Assembly (2007 Session) amends § 32.1-353.3 of the Code of Virginia (See Appendix A) to require:

• the Director of the Department of Medical Assistance Services (DMAS) to establish a Nursing Facility Quality Improvement Program; and,

• the Director of DMAS to provide a strategic plan and progress report to the Governor, Chairmen of the House Committees on Health, Welfare and Institutions, and Appropriations; the Senate Committees on Education and Health, and Finance; and the Joint Commission on Health Care no later than October 1, 2007.

This report is intended to fulfill this reporting requirement, specifically by providing recommendations on how the Commonwealth may use civil money penalty (CMP) funds collected from nursing facilities (NFs) that have been found to be out of compliance with Federal requirements to better the lives of the residents in nursing facilities. The proposed quality improvement program is a work in progress and will continue to be developed and refined over the next several months and years.

Section 1919 [42 U.S.C. 1396r],(h)(2)(A)(ii), specifies that "funds collected by a State as a result of imposition of such a penalty... shall be applied to the protection of the health or property of residents of nursing facilities that the State or the Secretary finds deficient, including payment for the costs of relocation of residents to other facilities, maintenance of operation of a facility pending correction of deficiencies or closure, and reimbursement of residents for personal funds.”

The federal law suggests the CMP revenues be applied to administrative expenses rather than direct care costs, although it is clear that states have broad latitude to determine which of these types of expenses best meets the needs of the residents. The Act permits each state to implement its own procedures with respect to the use of CMPs. However, this flexibility is limited by the requirement that CMP funds are to be focused on facilities that have been found to be deficient. The law does not specify when the NF must have been determined to be deficient to qualify for benefits under a state project funded by CMPs.

To address the new Code requirement for the development of a Nursing Facility Quality Improvement Program (QIP), the Department formed an interdisciplinary QIP Advisory Committee to discuss the issues and recommend an action plan. The committee included representatives from the Departments of Aging, Mental Health, Mental Retardation and Substance Abuse Services (DMHMRSAS), Health Professions, Health and Social Services, the Alzheimer’s Association, State Long-Term Care Ombudsman; Virginia Association for Home Care and Hospice, Virginia Coalition for the Aging, Virginia Health Care Association, the Tender Loving Care 4 Long Term Care Organization, the Virginia Association of Professional Nursing Assistants', Inc., the Virginia Association of Non-Profit Homes for the Aging, Virginia Health Quality Center, Lake Taylor Hospital, Westminster-Canterbury of the Blue Ridge, Legal Aid, Commonwealth Care of Roanoke, Inc., Virginia Poverty Law Center, Virginia Coalition for the Aging, Blue Ridge Legal Services, and the Virginia Office of Protection and Advocacy. (See Appendix B for the detailed list of participants.)

The Committee spent the summer of 2007 discussing the issues associated with quality improvement in nursing facilities. After this discussion, which included review of best practice models both nationally and within Virginia, the Committee agreed to pursue a quality improvement model similar to that utilized in North Carolina. The North Carolina program is described as a “meaningful and voluntary ‘raise the bar’ program pertaining to direct care staff recruitment and retention that would apply across long-term care related settings.”

The Committee agreed with the North Carolina theory that the recruitment and retention of qualified nursing staff would lead to an improved living environment for residents of nursing facilities. Through focused attention on the development of supportive workplaces, balanced workloads, training and career advancement opportunities, the program expects to improve the retention of quality direct care workers, resulting in an enhanced quality of life for nursing facility residents.

This document is intended as a roadmap for an improved long-term care system. There are items that should and can be implemented now; however, appropriate performance benchmarks to measure future impact will need to be developed and implemented as part of this process. Other recommendations could be reasonably tied to key benchmarks and implemented in the future. It is important to note that the Advisory Committee recognized that many of the recommendations in this report will have associated costs. The measure of such costs must be weighed against the high costs of staff turnover, and the concomitant costs of recruitment and training of new staff as well as the high cost of heavy reliance on agency ‘pool’ staff to fill staffing gaps when there is high turnover. In addition, in determining the costs of any recommendations, the costs of potential additional administrative costs on the nursing facilities must be considered. The bottom line, however, is that all costs incurred for this program will remain within the amount of funds that have been collected through the Civil Money Penalty process from Virginia nursing facilities and/or will have been secured through grants.